Question

The nurse in the neuro intensive care unit is caring for a client with a new C6 SCI whi is breathing independently. Which nursing interventions should be implemented? Select all that apply.

A.) Monitor the pulse oximetry reading.
B.) Provide pureed foods six (6) times a day.
C.) Encourage coughing and deep breathing.
D.) Assess for autonomic dysreflexia
E.) Administer intravenous corticosteroids.

Answer 1

When caring for a client with a new C6 spinal cord injury (SCI) who is breathing independently, the nurse should implement interventions such as monitoring pulse oximetry reading, encouraging coughing and deep breathing, and assessing for autonomic dysreflexia.

Step-by-step explanation:

When caring for a client with a new C6 spinal cord injury (SCI) who is breathing independently, the nurse should implement the following nursing interventions:

• Monitor the pulse oximetry reading: This is important to assess the client's oxygen saturation levels and ensure they are receiving adequate oxygenation.
• Encourage coughing and deep breathing: This helps prevent respiratory complications such as pneumonia and atelectasis.
• Assess for autonomic dysreflexia: Autonomic dysreflexia is a potentially life-threatening condition that can occur in clients with SCI above the T6 level. It is characterized by a sudden increase in blood pressure that can lead to a stroke or heart attack. Regular assessment is crucial for early detection and intervention.